Inspection on 08/02/07 for Astley Grange Nursing Home

This inspection was carried out on 8th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Astley Grange Nursing Home 21/02/08

Astley Grange Nursing Home 12/10/05

Astley Grange Nursing Home 18/04/05

Astley Grange Nursing Home 08/09/04

Astley Grange Nursing Home 21/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Astley Grange Nursing Home 288 Blackburn Road Bolton Lancashire BL1 8DU Lead Inspector Grace Tarney Unannounced Inspection 8th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley Grange Nursing Home Address 288 Blackburn Road Bolton Lancashire BL1 8DU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01204 365435 01204 392687 astley.grange@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Barbara Jean Oakes Care Home 30 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (30), of places Physical disability (3), Terminally ill (3) Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users, to include: up to 30 service users in the category of Older People (OP), up to 7 service users in the category of Dementia over 65 years (DE(E)), up to 3 service users in the category of Terminal Illness under 65 years (TI) and up to 3 service users in the category of Physical Disabilities under 65 years of age (PD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th October 2005 2. Date of last inspection Brief Description of the Service: Astley Grange is a two-storey property, situated on a main road on the outskirts of Bolton Town Centre. It is within easy reach of bus routes, shops, and other community facilities and is not too far from the motorway network. The home has 24 single bedrooms and 4 doubles. There is a lounge on each floor, a dining room on the ground floor, and bathrooms and toilets on both floors. The home is fitted with adaptations and equipment suited to the needs of the resident group. Equipment includes a passenger lift and ramped access. Outside, there is a small parking area at the front of the home, and an enclosed garden at the side. It is registered to care for people with mainly nursing needs and because of this 24 hour qualified nurse cover is provided. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection, questionnaires (comment cards) were sent out to the residents, their relatives, GPs and to the home itself. The questionnaires that were sent out to the residents were called Have Your Say and they asked what people thought of the quality of the service and the facilities provided. 8 questionnaires were returned from residents, 8 from relatives and 3 from GPs. What they felt about the care and facilities is written in different sections throughout this report. The Inspector spent a total of 7 hours at the home. During this time she looked at care and medicine records to ensure that the health and care needs of the residents were being met. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at some of the maintenance and service records of the equipment within the home. How the home manages the residents’ spending money was also looked at. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms and lounge areas. This was to check out the care that was being provided for them. The Inspector also looked at what the residents had for their lunch and evening meal. In order to get further information about the home the Inspector also spent time speaking to 3 residents, 2 relatives, the qualified nurse on duty, 2 care assistants, the activities organiser, the administrator and the cook. A copy of the last inspection report is kept in the reception area. The provider informed the inspector that the fees within the home ranged from £345.04 per week for local authority funded people to £445.00 per week for those residents paying privately. This information was received on the 21/11/06. What the service does well: Before residents went into the home, the nurse manager or one of the senior nurses visited them in their own homes or in hospital to make sure that the care they needed could be provided by the home. The qualified nurses and care staff were extremely good at caring for the residents who were very ill and needed lots of specialised care. The staff made sure that all the necessary equipment needed for their care was available. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 6 The nurses made sure that they continually look at anything that may be a risk to the residents. They then make sure that they write down in the residents care plan when they have done this, and what action they have taken to reduce the risk. Activities were considered to be a very important part of the residents’ day. The activities person who worked at the home was aware of what each resident liked, and was able, to do. Comments such as “They are all very good” “ I feel he has improved since he came here”, “The nursing care is excellent” were made to the Inspector. People visiting the home are made welcome and can visit at any reasonable time. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. Residents had a detailed assessment undertaken before their admission to the home and this gives an assurance both to residents, relatives and staff, that a resident is only admitted if the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspection of 3 resident care files showed that before they were admitted to the home an assessment of their needs had been undertaken either by the manager or a senior member of the nursing staff. The resident files also had assessments undertaken either by the residents’ social worker or from the hospital they were admitted from. The assessments are necessary so that the home can be sure that they can meet the residents’ needs. Standard 6 does not apply. The home does not provide Intermediate Care. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is excellent. The residents’ health care needs were fully met and they received their medicines correctly and safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans were in place for each resident. The care plans of 3 of the residents were inspected. The care plans were very detailed and gave clear instruction and guidance on how the care needs of the residents were to be met when problems had been identified. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. They also assessed if it was safe to use bed rails. Risk assessments were also in place for whether a resident was at risk of falling. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 10 Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians and chiropodists. Inspection of the care plan of a resident who had been admitted to the home from hospital with pressure sores, showed that the nursing staff had sought the advice of a nurse who specialised in the care of pressure sores. Equipment necessary for the prevention and treatment of pressure sores was available and in use. Residents were weighed at least on a monthly basis. In answer to the questions on the Have Your Say Questionnaire – 1.Do you receive the care and support you need? The following comments were made: 7 residents said always and 1said usually. 2.Do you receive the medical support you need? 6 said always, 1 said usually and 1 said sometimes. The comments from the GPs were all positive. They stated that the home communicated clearly and worked in partnership with them. Following a discussion with 2 relatives the following comments were made: “I am very satisfied with the care provided here” “The nursing care is excellent”. “ My husband is always clean and I feel that he is more contented”. “ I cannot fault them”. A safe system of medicine management was in place. The home does not have a separate medicine room. Medicines are kept in the nurses’ office in locked cupboards and in the medicine trolley. The medication keys were held securely and the trolley was secured to the wall when not in use. Controlled drugs were stored and recorded, correctly and safely. The following areas needed addressing: • A handwritten instruction for medicines (Transcriptions) was not checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. • The residents’ stocks of medication were not divided into individual sections. Separating the resident stocks ensures the correct rotation of medicines and reduces the risk of any drug errors. Staff were seen to be discreet when providing assistance. Staff demonstrated by example their knowledge of maintaining privacy and dignity, by knocking on doors, closing toilet doors etc. Residents were well groomed and dressed. A resident told the Inspector that the staff “treat me well”. One relative said that she felt the staff were very respectful to the residents. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15. Quality in this outcome area is good. The home enabled residents to exercise as much personal freedom and choice as possible and find enjoyment with the range of activities available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans. The home employs an experienced activities organiser who works 20 hours each week and organises and implements a programme of activities for the residents. A wide range of activities is offered at the home including table and floor games, knitting, crocheting and various arts and crafts. The activities organiser told the Inspector that she discusses with any outside entertainers what would be suitable for the residents. The activities organiser also offers individual activities to residents and in discussion it was apparent that she knows the residents well. She is also starting resident/relative meetings so that issues around activities/trips out can be discussed and arranged. That is really good practice. In answer to the question on the Have Your Say Questionnaire the following comments were made: Are there activities arranged by the home that you can take part in? 3 said always and five said usually. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 12 A relative confirmed that there were no unreasonable restrictions on her visiting her relation at the home and that visits could be conducted in the privacy of the resident’s room. One relative told the Inspector that she visits every day and is always made very welcome. The Inspector saw some detailed policies on spiritual care and guidelines in relation to different religions. Staff told the inspectors that the residents are encouraged to bring personal possessions into the home. Some of their bedrooms were personalised with small pieces of their own furniture, pictures, photographs and ornaments etc The Inspector did not dine with the residents but observed lunch being served. The tables were nicely set with napkins and condiments. The residents have the main meal at lunchtime and the lighter meal in the evening. The lunch that day was meat and potato pie with two vegetables. For the sweet it was eves pudding and custard. Both dishes were home cooked. There wasnt an active choice of a main meal but both the kitchen and care staff told the Inspector that the residents could have more or less anything they wanted as there were plenty of food stocks. The Chef told the Inspector that he would cook an omelette or make a jacket potato with any filling that they requested. Hot and cold drinks were available. In answer to the question on the Have Your Say Questionnaire the following comments were made: Do you like the meals at the home? 3 said always, 4 said usually. The question was not relevant for one resident who was fed artificially. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. The complaint system in place enabled residents to feel that their views were listened to and acted upon. Staff had a good knowledge and understanding of adult protection procedures thereby reducing the possible risk of harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure was in place and was displayed in the reception area. It appeared to be an old complaints procedure because it made reference to contacting the relevant registration and inspection authorities. It also stated that the names and addresses of these authorities were alongside the notice. They were not. The administrator agreed to change the complaints procedure as soon as she was aware of the new address and telephone number of the local office of the CSCI. The complaints procedure was included in the Service User Guide. A discussion with residents and a relative indicated that there was a general awareness of how to make a complaint. It was clear in discussion with staff that they also knew what steps to take should a resident make a complaint. No complaints had been made to either the home or the CSCI in the last 12 months. In answer to the questions on the Have Your Say Questionnaire the following comments were made Do you know who to speak to if you are not happy? 5 said always, 2 said sometimes and 1 said usually. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 14 Do you know how to make a complaint? 3 said always, 2 said usually,3 said never had to, and 1 person stated that there was no reason to complain. A policy and procedure was in place in relation to the detection of abuse and neglect (including whistle-blowing) and how to respond to suspected abuse. The home had a copy of the Local Authorities procedure for protection of vulnerable adults. A discussion with care staff showed that they were aware of the different forms of abuse and the procedure to follow in the event of any allegation of abuse. Training records were inspected and showed that training in the protection of vulnerable adults had been undertaken and was an ongoing process. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 &26. Quality in this outcome area is good. The residents live in suitably adapted, clean and comfortable surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The front porch and reception area are very welcoming with adequate seating for the residents and visitors. The reception area is where the administrators’ and the managers’ offices are situated. The corridors are wide with grab rails along the side to assist the residents with mobility problems. There is a lounge on each floor, a dining room on the ground floor, and bathrooms and toilets on both floors. Doors from the dining room lead on to an enclosed garden area. Both lounges and the dining room were clean, warm and suitably furnished. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were in close proximity to bedrooms and communal areas. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 16 The toilets were clean and most were suitably adapted for disabled use. One of the toilets however had no disabled assistance and was without a nurse call system. It was unclear during the inspection whether this was a designated staff toilet or not. If it is a designated staff toilet it should be identified as such. One of the toilets also had an unguarded radiator in place and one of the bathrooms had unguarded hot water pipes leading to the sink. One of the bathrooms had a nurse call lead to the shower but a resident would not be able to reach this if they were using the toilet. All the bedrooms were looked at. Some of the bedrooms were better decorated than others but they were all clean, warm and suitably furnished. The Inspector was informed that a redecoration and refurbishment programme is in place. Apart from bedroom 9 all the bedroom doors had an overriding door lock in place. Several of the bedrooms were without a lockable space. In answer to the questions on the Have Your Say Questionnaire the following comments were made Is the home fresh and clean? 6 said always and 2 said usually. Other comments made were “I decided on here because of the homely atmosphere and cleanliness” The heating within the home was adequate. All the rooms were centrally heated with, apart from 1 of the toilets, radiators that were suitably protected. The Inspector was told that thermostatic control valves were in place on immersion baths and showers. Inspection of the service record for the thermostatic control valves confirmed this. The home was clean and free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. Clinical waste was handled appropriately and the home had a contract for the removal of clinical waste. The laundry area was clean, well equipped and looked well organised. . Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is good. The residents were being cared for by caring and conscientious staff that were safely recruited and trained and therefore had the knowledge and skills to meet the residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the duty rotas and a discussion with staff, relatives and residents plus comments from the questionnaires showed that there was enough staff on duty to meet the residents’ needs. The Inspector at first found the duty rotas difficult to understand. The rotas do not reflect the actual times of the shifts worked and do not document whether the staff are qualified nurses or care assistants. There should be a recorded staff rota showing which staff are on duty at any time during the day and night and in what capacity they are working. If management feel that they do not want to change the system in place then they need to have some code in place to identify the start and finish of each shift. The staff were seen to have a natural and comfortable understanding with the residents and they had time to sit and talk with them. One relative commented, “ I feel the staff are very loving and caring. ” Information from the pre-inspection questionnaire showed that of the 15 care staff employed, 9 have obtained their NVQ level 2 or above in care. This is a percentage of 59 and therefore the home has met the Standard. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 18 The pre-inspection questionnaire also details that NVQ 2 and NVQ 3 training for staff is ongoing and the current candidates will have finished their courses by the end of February 2007. The personnel files of 3 staff members were inspected. All were in order and these staff had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal records disclosure (CRB) or POVA 1st check and a health status declaration. The Inspector also saw that the home keeps a check on the nursing staff’s registration status to make sure that as required, such registrations are up to date with the Nursing and Midwifery Council. Inspection of the same 3 personnel files showed that the staff received induction training within six weeks of appointment to their post and further training within the first six months of appointment. The induction and foundation training was in accordance with the National Training Organisation (NTO) specifications. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38. Quality in this outcome area is good. The managers experience and qualifications ensured that current practices within the home promoted and safeguarded the health, safety and welfare of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a Registered General Nurse (RGN) and has a lot of experience working within the private sector. She has worked at the home since 1997. She has a recognised teaching and assessor qualification and has also obtained the NVQ level 4 in management award. She keeps herself updated by attending various courses. On the day of the inspection she was not present in the home as she was on a training course about nutrition. The manager is very skilled at caring for the residents, and both residents and staff spoke very positively about her attitude, kindness and knowledge. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 20 The company has its own Quality Assurance system in place. The Registered Manager is required to undertake a monthly internal audit. This includes exploring issues related to the environment such as health and safety, pressure care survey, accident statistics, care plan audit and medication. Feedback is sought using the customer feedback surveys, which are sent out on a 6-monthly basis. A suggestions box is sited in reception and also residents and relatives are invited to express their views at the three-monthly residents and relatives meetings. There is also a comments book in the dining room for residents to give their opinions about the food. The system in place for the management of the residents’ pocket money was good. Their families generally undertake the management of residents’ finances. Generally only personal allowances are held by the home in a residents’ account. Individual computer records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any “spending money” for their relative. The home had a detailed Health & Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. The one concern identified was in relation to the unguarded radiator in a toilet and the unguarded hot water pipes in a bathroom. Any accidents that happen are properly recorded and monitored. Information obtained from the pre-inspection questionnaire and from random checking of servicing records showed that the homes fixtures, fitting and equipment are properly maintained and regularly serviced. Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x 2 x x 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP21 Regulation 23(2)(n) Requirement To make sure that residents can summons assistance whilst using the toilet a nurse call lead must be in place near the toilet in the shower room. To make sure that the resident has the right to have their privacy and dignity respected a lock must be fitted to the door of bedroom 9. Residents have the right to keep safe anything that is of value to them. A lockable space must be provided for them in their room. The residents must be protected from the risk of injury by burns from either the unguarded radiator or unguarded water pipes. To make sure that they are protected the radiator must be covered or a low surface radiator fitted and the pipes must be boxed in. Timescale for action 31/03/07 2 OP24 12(4)(a) 31/03/07 3 OP24 23(2)(m) 30/06/07 4 OP25 13(4)(a) 31/03/07 Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Residents’stock medications should be segregated into a form of order Separating the resident stocks ensures the correct rotation of medicines and reduces the risk of any drug errors. To ensure the accuracy of a transcription, handwritten transcriptions should be checked with another member of staff, signed and countersigned 2 OP9 Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Astley Grange Nursing Home DS0000005671.V297303.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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